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The HIV / AIDS Epidemic in the Russian Federation
Dave Burrows this text may be freely published and distributed for non-profit purposes and under mentioning of the author and source. please notify the author at Dbsyd@aol.com . bio -- Introduction -- The relatively delayed arrival of HIV / AIDS in Russia in 1987, combined with the country's isolated (political) position in the world had led to a lack of knowledge on HIV / AIDS prevention among its medical professionals, political decision makers and the general population at large. The socio-economic upheaval in Russia and the other Newly Independent States (NIS) republics caused by the collapse of the Soviet Union has seriously hampered the health system's ability to respond to new problems such as the HIV epidemic. The health system is over-expanded and under-funded. This has led to material shortages and non-payment of salaries, both of which have hurt the capacity and morale of health care workers. The same socio-economic changes have a serious impact on the health status of the population. Poverty is on the rise. Extensive population movements are taking place within the NIS. Commercial sex work has become a common trade and high rates of Syphilis infections throughout the region indicate a high level of unprotected sex. The use of injectable illicit drugs is widespread among young people. Through sharing of equipment, the HIV virus is especially spreading fast among injecting drug users, from where it threatens to spread towards the general population by sexual transmission. Repressive anti-drug laws are causing the imprisonment of increasing numbers of HIV-positive individuals (mostly injecting drug users). The Russian parliament estimated in 1997 there were more than 2.500.000 drug users in the total population of about 142 million. As seen in HIV / AIDS epidemics in other countries, infection spreads extremely quickly through this injecting drug using population. Some cities (Edinburgh, Bangkok, and Manipur) experienced 40% of injecting drug users being infected in a single year. Currently over 90% of new HIV infections in Russia are among injecting drug users. By 1999 and 2000, the world's steepest HIV curve was recorded in the Newly Independent States (NIS) of the former Soviet Union, where the number of people living with HIV / AIDS more than doubled each year. Russia, Ukraine, Belarus and Kazakhstan are the hardest hit by the HIV / AIDS epidemic in the region so far. By May 2001, a total of 113.323 people have been officially registered with HIV in Russia. According to the World Health Organisation and UNAIDS, the real number of people living with HIV / AIDS in Russia is five to ten times the number of registered cases: this means that at this moment between 550.000 and 1.100.000 persons in Russia are living with HIV or AIDS. The Russian Federal AIDS Centre predicts this figure to rise to 5 million Russians living with HIV / AIDS by the end of 2005. The United States Central Intelligence Agency has predicted that HIV / AIDS will most likely continue to expand in the developing and transitional world for the next 20 years at least, and that the former Soviet Union would be one of the worst affected regions during this period. As increasing numbers of people with HIV develop medical problems associated with AIDS, they will soon start to overwhelm the health structures of these countries. To prevent further worsening of the epidemic and to assist Russia and other NIS republics to deal with the massive HIV / AIDS epidemic in the region, a new approach is necessary. Approach The principles of harm reduction Harm reduction is one of the three complementary approaches to addressing drug issues and its harmful consequences, the others being supply reduction and demand reduction. Supply reduction includes seizing drugs through customs operations and assisting drug producers to stop growing, for example, opium poppies and substitute these with other, legal, crops. It also includes arresting drug traffickers and breaking up supply routes for illicit drugs. Demand reduction is a complex of measures, usually provided by social, education and medical services, to promote a healthy life-style free from drugs, and to assist drug users to stop using and achieve medical and social rehabilitation. Harm reduction policies, strategies and activities aim to limit or reduce the nature and extent of adverse consequences of drug use, related to:
The harm reduction approach is based on a realistic acknowledgement that there are no known interventions for completely eliminating drug use or drug related problems in any city, community or country. The principles of harm reduction work with IDUs include:
The main type of harm reduction programs used in the Russian Federation is needle and syringe exchange, together with counseling, outreach, peer education and support, and other activities connected with needle exchange. By early 2001, there are at least 48 needle and syringe exchange programs (NSEPs) in the Russian Federation, from Kaliningrad in the west to Khabarovsk in the east, and from Archangelsk in the north to Astrakhan in the south. Needle exchange and other preventive health activities So, why needle exchange? Why do so many health professionals in Russia and in other countries believe that needle exchange programs are an important part of HIV prevention among IDUs? The riskiest activity for HIV infection during injection is frequent sharing of injecting equipment with strangers. Needle exchange or distribution prevents or reduces this practice. There are now 134 countries world-wide reporting the practice of injecting drugs for recreational or non-medical purposes. Of these countries, 114 have reported HIV infection among IDUs, with 46 countries implementing at least one needle and syringe provision or needle and syringe exchange program. Needle and syringe exchange programs have been studied in many different countries and in great detail due to the controversy surrounding their introduction. United States government reports have found that, following the introduction of needle exchange to a city or country, there is: no increase in the number of drug injectors; no increase in drug use; no reports to contradict these findings. An evaluation of Australian needle and syringe exchange programs found that these programs had saved an estimated 3.000 lives in a single year at a cost of about US$200 per life saved. The savings in HIV treatment costs were estimated to be about US$150 million. A world-wide survey found that in cities with needle exchange, HIV seroprevalence among IDUs decreased by 5.8% per year. In cities without needle exchange, HIV seroprevalence among IDUs increased by 5.9% per year. Changing social norms As well as risks from sharing needles and syringes, there are added HIV transmission risks in drug preparation, manufacture and purchase (such as purchase of liquid drugs in syringes that may not be sterile). NSEPs and educational programs also need to address drug users' sexual behaviour through prevention education (use of condoms, negotiation of safe sex) and condom distribution. Focus groups, in-depth interviewing and the use of ethnographic methods such as observation, can identify HIV transmission points and assist in understanding the social nature of drug users' lives. On the basis of this information, education programs can develop appropriate prevention strategies. The goal of such strategies must be to change the social norms surrounding drug injecting and sexual behaviour. By encouraging a large percentage of injectors to switch to safer behaviours, HIV prevention becomes the norm. Accompanying a change in social norms, each individual drug user must decide to protect his/her health: many IDUs do not worry about HIV infection, despite the realisation that HIV infection will cause serious physical problems and will likely lead to death (especially in transitional and developing countries). This appears to be the result of internalisation of negative attitudes towards drug users expressed by parents, media, health care workers, militia and the general community. Increasing NSEP effectiveness Several features of NSEPs are generally believed to increase their effectiveness. A properly organized NSEP unit, stationary or mobile, is the centre of access to a hidden group of drug users who might never otherwise access medical or social services. Provision of sterile needles and syringes, collection of used needles and syringes, provision of sterile swabs, condoms, booklets and other explicit targeted education materials, contact information about relevant services, and consultations on various questions (not only medical) are integral activities of exchange programs. The siting of NSEPs is important: locating the NSEP so that it is convenient to large numbers of IDUs may be critical for effective HIV prevention. Continuity of service is also important. An evaluation of Italian NSEPs found that continuity of funding and service was vital to the programs' success in attracting and maintaining relationships with IDUs. The closure of a NSEP can also have a serious impact on HIV risk behaviours among IDUs. When an United States NSEP was closed in 1997, significant increases were found in the percentage of IDUs re-using syringes more frequently and sharing needles and syringes. Most NSEPs use outreach to ensure their activities extend throughout various social networks of IDUs. Outreach work has been extensively studied. Even without an attached NSEP, in Chicago, a large outreach program achieved a reduction in risky behaviours from 100% to 14% over four years and the rate of HIV infection fell from 5% to 1% per semester by the last six months of the study. Under the National AIDS Demonstration and Research (NADR) project, the United Stated National Institute on Drug Abuse (NIDA) funded outreach projects in 68 cities of the country. Published results of the outreach work in 20 cities found dramatic decreases in risky behaviour among program clients. For example, the proportion of clients judged to be at high risk of infection with HIV through shared injecting equipment fell from 62% prior to receiving outreach to 31% at a six-month follow-up interview, and similar decreases (16% to 8%) were noted in the proportion of clients judged to be at high sexual risk. Outreach work is usually needed to identify networks of IDUs, introduce them to the NSEP's services, build up trust between NSEP staff and IDUs, (in some cases) distribute sterile injecting equipment and educational materials, and/or carry out research on the needs of IDUs. However, outreach work (whether or not it is connected to a NSEP) is unlikely to reach sufficient numbers of IDUs across a wide range of social networks in a short enough period to prevent fast-moving HIV epidemics. Social norms of injecting will only change with the active involvement of IDUs themselves. This involvement can take many forms but most commonly at NSEPs, it involves peer education and/or peer support. In peer education, active IDUs are trained to educate other IDUs about HIV risks and safer injecting and safe sex practices. A study of Australian NSEPs found that peer education was regarded as an essential element in their work and a European study of 2.554 IDUs in Greece, France, Italy, Portugal and Spain found that educational materials were much better accepted by IDUs when they were distributed by "friendly contact" from another IDU, rather than from a counselor or other professional. In peer support, this process is broadened so that IDUs are involved in all aspects of defining what issues need to be addressed, what types of educational and other strategies should be employed, as well as carrying out the education and other processes and, in some cases, evaluating and reporting on their work. Peer support programs began in the 1980s in the Netherlands and quickly spread to Germany, the United Kingdom, Norway, Denmark, France, Belgium, Italy, Spain, Australia and New Zealand. More recently, peer support groups are being established in the transitional and developing world in countries such as India, Brazil, Bangladesh, Slovenia and the Russian Federation. Fostering peer support is increasingly being regarded as an important part of effective NSEP practice. There is a strong need to reach IDUs at highest risk for acquiring HIV. Specific programs may be needed to target women IDUs (especially those who are sex workers); gay and lesbian IDUs; street youth (whether injecting or pre-injecting); and IDUs of specific ethnicity who are often marginalized such as Roma in Eastern Europe, Vietnamese in Australia, North African in France, etc. Women IDUs who are also sex workers are increasingly regarded as the main nexus of injecting-related and sexually transmitted HIV epidemics. This group should be at least as high a priority as male IDUs, especially in those countries where a significant proportion of female IDUs are also sex workers (such as Eastern and Western Europe, North America and Australia, and some cities or countries in Asia and South America). The experience of establishing and running NSEPs in many countries around the world has confirmed the vital importance of gaining - and maintaining - support from local authorities and communities. Research has shown that NSEPs are most likely to work effectively if they are well managed, sufficiently financed, free from police harassment and linked with health and other social services. Many techniques are used to ensure that the local community accepts the NSEP's services and, eventually, supports the program's work. However, in almost every country, there are serious difficulties between the operation of NSEPs and law enforcement activities directed towards preventing drug selling and buying and, in some cases, drug possession and use. This is a seldom-researched topic, though it is often discussed by NSEP practitioners. The research which has been done suggests that hostile police activities can have devastating effects on a NSEP's work: for example, client contacts fell by 40% in an Australian NSEP one month after a sustained police operation targeting drug users in the local area around the fixed-site NSEP. Results in the Russian Federation (RF) Harm reduction training in RF Most of the currently existing 48 NSEPs in Russia started as a result of a training program by Medecins Sans Frontieres - Holland (MSF-H), as well as technical assistance and funding from Open Society Institute - Russia (OSI-R) and International Harm Reduction Development in New York. In September 1997, MSF-H began an extensive training program to ensure that people working on HIV prevention among IDUs in the Russian Federation have the following skills:
The training course was based on the Rapid Assessment and Response Guide on Injecting Drug Use developed by the World Health Organisation "Program on Substance Abuse" in collaboration with UNAIDS and the Center for Research on Drugs and Health Behaviour in London; and the European Peer Support Manual developed by the Trimbos Institute for the European Commission and significant scientific articles and books. Rapid Assessment and Response (RAR) is an action research approach that consists of three main components: assessment methods and sources of data; key areas of assessment; and the development of action plans for intervention implementation. A total of 199 participants from 61 cities attended the training course. The largest participant groups were from government AIDS centres (68) and narcological (drug treatment) hospitals and dispensaries (60), while about one-quarter of all participants attended from non-governmental organisations, and the other participants attended from government infectious diseases hospitals and research institutions. By June 2000, 35 program proposals from these training participants were approved for funding by Open Society Institute - Russia. As there were four HIV prevention interventions among IDUs in Russia at the beginning of the training program, this amounts to around a 900% increase in HIV prevention programs among IDUs in Russian Federation in 30 months. Effectiveness of Russian NSEPs In April 2001, initial data were released from two projects that are evaluating the introduction of NSEPs in Russian Federation. Preliminary data were provided from a large evaluation undertaken in 1999/2000 of NSEP clients in Nizhny Novgorod, Pskov, Rostov-on-Don, St Petersburg and Volgograd. These data showed substantial reductions in previously identified injection risk behaviors, such as needle sharing, from the time prior to using the exchanges and generally low rates of the same behavior while using the exchanges. The percentages of respondents reporting receptive syringe sharing - sharing by receiving rather than giving a syringe - are close to those in effective NSEPs in other countries. However, the authors also found that some risk behaviours remained unchanged after the opening of NSEPs. Specifically, the study found significant reductions in receptive syringe sharing; injecting at an anonymous injecting venue (or "shooting gallery"); and buying drugs already loaded in a syringe. However, injecting in a group, sharing utensils such as the vial in which drugs are produced, and the use of syringes to share drugs between several syringes in group injecting did not change significantly. The authors pointed out that these final three behaviours are tied closely to the group preparation of liquid drugs. It is yet to be determined how the widespread introduction of heroin, as exists today, would affect these behaviors. Preliminary data from a study in Sverdlovsk oblast showed similar results. A baseline survey was carried out prior to the opening of NSEPs in Sverdlovsk, then these data were compared with two groups: those IDUs who had been attending an NSEP for at least three months and those who had never attended a NSEP. Some preliminary results are that those attending the NSEP were more likely to only use their own needle, syringe, filter and drug solution and were less likely to use syringes to share drugs between several syringes in group injecting. However, purchasing ready-made drugs was virtually unchanged by NSEP attendance, and the effects of the NSEP on numbers of IDUs adding blood to drug solutions was the opposite of the intended effect. Again, this is likely to change due to changes in drug use patterns, but this finding emphasises the need for NSEPs to concentrate on the social nature of drug preparation and use. Conclusion An evaluation of prevention work among injecting drug users in early 2001 discovered several, very positive findings. When harm reduction work began in RF in 1996, few people working on the issue would have believed that there would be 48 functioning needle and syringe exchange programs (NSEPs) operating across RF less than five years later. The evaluation found that the level and breadth of services was already good but that the quality and reach of the services needed to be increased. A comprehensive multi-disciplinary approach is needed to address the epidemic effectively in which all key players, notably people affected and those living with HIV and AIDS, take part in decision-making, design of programs and executing of activities. Russia and the other states of the former Soviet Union are still in the position to benefit from the global experiences on HIV / AIDS prevention and can avert the disastrous impact this epidemic has had on many other countries. Vision, commitment and leadership at the highest political level are needed to support and encourage these developments. The newly-established international, humanitarian organisation AIDS Foundation East-West, being the successor of the current MSF-H HIV / AIDS programs in the NIS, is committed to initiate and support the development and implementation of innovative and appropriate HIV / AIDS prevention, and care and support programs in the NIS. Dave Burrows May 2001 Dave Burrows
bio Dave Burrows is an independent consultant on HIV / AIDS and hepatitis prevention, care and support among injecting drug users. He has worked in 15 countries with most of his work in the past four years in Russia, Ukraine and Indonesia. He is based in Australia. |
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